An aviation researcher, writer, aviation participant, pilot & agricultural researcher. Author of over 35 scientific publications world wide.


Good reads

Oil Prices


Birds? What birds? A litany of mistruths by CASA

With permission:

Birds? What birds?

Updated December 10, 2011

An Administrative Appeals Tribunal (AAT) decision delivered on October 12 has a large number of people in aviation – particularly helicopter pilots and operators – carefully studying its implications and the lessons to be learned and stored.

A North Queensland helicopter pilot was in effect fired from his job following a brief meeting with a CASA official and another pilot from his company who was awaiting CASA approval as his employer’s new chief pilot.

The pilot concerned was told CASA had seen a video on You Tube that had been recorded on one of his scenic flights, and was then accused of various acts of flying misconduct but was provided with no supporting detail. He denied the allegations, not believing he had ever conducted a flight in the manner he was accused of which varied considerably from anything in his memory suggested. He was then excluded from the meeting, after which his company suspended him from duty. Because his only income was an hourly rate while flying, that meant that he was in effect unemployed.

The events that followed will be a useful guideline to what anybody can expect if CASA decides that they have breached the regulations – and also what they cannot expect. The conduct recounted here will have a familiar ring to many who have already experienced similar treatment.This especially applies to pilots and operators who do not belong to a large organisation with a capable and well funded legal department.


None of this analysis is intended to denigrate individuals or organisations. Instead we recount what happened and leave you to form your own opinions.  Our views are expressed in paragraphs labeled “Comment:” which represent the opinion of the author.

Grounded indefinitely:

It is now nearly three years since CASA’s senior FOI at Cairns, Dennis Allwood, arranged the meeting that in effect resulted in North Queensland commercial helicopter pilot John Quadrio being summarily kicked out of the industry. That outcome was achieved without the production of any valid evidence and without any formal regulatory action at all. The action, which required the cooperation of the CASA certificate holder who employed him, was taken on the basis of untested allegations against Mr Quadrio that had come from an unusually dodgy source.

Mr Quadrio – we’ll just call in John from here on – is a mature-age pilot from a farming background who enjoyed a reputation as a conscientious and safety-minded helicopter pilot. He was employed by Cairns-based commercial helicopter operator Heli Charters, much whose operations are scenic flights from helipads on the Great Barrier Reef near Cairns, flying small groups of tourists whose day cruise craft visits the pontoon.

Their operating environment is outside but close to controlled airspace, and pilots have to manage each flight with continuous care because of pretty high traffic levels, with hundreds of tourists visiting Cairns wanting to see the reef from the air, and a number of helicopter and fixed wing operators are there to serve that market.

The other hazard is bird encounters which are a daily occurrence, and on some days it’s a continuous problem that can only be managed by a constant and alert lookout. Frequent avoidance manoeuvring is so routine for any pilot operating these flights that it’s all in a day’s work and is not remarkable.

John says that had Mr Allwood accepted the offer of a visit to Hastings Reef he would have been far better informed on this issue, including the frequency and variety of bird life and the ample evidence of it that has to be cleaned off the helipad and other assets there quite regularly.

At the time of these events John had 735 total flying hours of which most were in Heli Charters aircraft over the previous two years. Corporate and government clients often requested his services because they appreciated his safety-first approach to flying.

John recalls the first time he became aware there was any issue at all: “CASA first raised it in early November 2008 with Noel Stubbs, the Chief Pilot at the time of the alleged incident. A passenger on a scenic flight had used a mobile phone to take a series of video clips that had been edited, compiled and posted on ‘You Tube’ under the title: Aerobatics in a Robinson R44 over the reef off Cairns, he says:

“When Noel Stubbs viewed the footage he told Allwood it wasn’t a ‘steep turn,’ it was ‘a wingover,’ a manoeuvre that’s taught in the CASA helicopter training syllabus, and he was happy to take him out and demonstrate that, but Allwood wasn’t interested. Noel also told Allwood that he didn’t have any problems with the flying but had advised all his pilots to ‘tame it down a bit.’ He did show all the Heli Charters pilots the video footage but at the time I thought it was a different pilot. I didn’t recognise it as my flying but I saw nothing wrong with the manoeuvring.”

For the unfamiliar a ‘wingover’ is a turning manoeuvre that is similar whether you’re flying a helicopter or an aeroplane. It’s specifically taught in the CASA-approved helicopter pilot training syllabus because it’s a far less aggressive alternative to a steep turn; it accomplishes a change of direction at relatively low airspeed within a small turning radius but without any sudden changes in pitch attitude, or “G” force. It needs only moderate engine power, and causes no increased stress on the aircraft, pilot or passengers. A steep turn is usually defined as a sustained turn using an angle of bank of 60° or more, which applies “G force” in proportion to speed, turn radius and bank angle, and in some definitions is classified as an ‘aerobatic’ manoeuvre.

“First my employer was pressured by CASA to suspend me before they had conducted a proper investigation.”

“Allwood apparently saw the opportunity to have another go when Noel Stubbs left,” says John. “The first time I knew it was me they were looking for, was on the day Casey McKenzie, the new nominee for the chief pilot position, took me to a meeting with Mr Allwood at CASA’s Cairns office on December 18, 2008.”

At that time Mr McKenzie was awaiting approval from Mr Allwood’s office of his proposed appointment as chief pilot of Heli Charters. CASA issues chief pilot approvals, which can be a very helpful boost to a pilot’s career prospects, but the regulator can just as easily decline to approve them or withdraw them, without the decision being appealable in the AAT because it is supposed to be based on an objective assessment through a personal interview. The exposure of the approval to non-appealable withdrawal is well known to limit disagreement on operational matters between chief pilots and the officials who approve their appointments.

“I told them I didn’t recall the flight, and that I don’t fly in the manner in which they were alleging,” says John. “Casey then asked me to leave the room, and he had a private conversation with them during which, he later informed me, he was asked by CASA to ‘take disciplinary action against the pilot.’ He told me he asked CASA ‘What do you suggest – I stand him down?’ to which, I was told, Dennis Allwood replied ‘That’s exactly what we are suggesting.’  Since then Casey McKenzie will neither confirm nor deny the particulars of that conversation however.”

Mr Allwood’s version of this event, as conveyed in his record of interview, claims that Mr Mackenzie volunteered that he would suspend John from duty “until the results of the investigation were known.”

On the same day Heli Charters wrote to John saying that a flight he allegedly conducted on 28th September 2008: “appears to be in violation of several CASA rules as well as the Heli Charters Operations Manual. I have therefore been left no choice but to suspend you from all flying duties until further notice.” A copy of that letter was also sent to CASA.

John had thus been consigned to unemployment without any transparent investigation, without any detailed discussion about the allegations or their validity, and obviously without seriously reviewing the range of options published in CASA’s own Compliance and Enforcement Manual (since renamed Enforcement Manual):

One immediate outcome was to force John and his wife Sophie to suspend plans for building a new house on their property on the Atherton Tablelands, because they didn’t believe the banks would be willing to provide a loan while John was without a steady income.

On February 3 2009, John received a call from Mr John Moore, an investigator from CASA’s Canberra office: “I told him I think it stinks that I have been suspended when I haven’t even been charged, let alone proven guilty. I said I thought in this country you were meant to be ‘innocent until proven guilty’. He told me that as far as he was concerned my licence was not suspended. He suggested I might like to get legal representation and then gave me his phone number to give to my lawyer.”

Later that day John phoned Steve Spinaze – his boss at Heli Charters – to advise he was available to fly for the company, but Spinaze said he wasn’t prepared to reinstate him without a letter from CASA confirming he was not suspended. No such letter was forthcoming.

Mr Moore, based on first observations of the YouTube video by CASA FOI Yvette Lutze, also recommended to his supervisors that John be prosecuted pursuant to the regulations quoted below along with our summary of their content:

1. Section 20A of the Civil Aviation Act: Reckless operation of an aircraft;

Under this section it is an offence to operate an aircraft being reckless as to whether the manner of operation could endanger the life or property of another person.

2. Civil Aviation Regulation 157: Low flying

The relevant part of CAR 157 says the pilot in command of a helicopter must not fly it over any area at a height lower than 500 feet above the highest point of the terrain, and any object on it, within a radius of 300 metres from a point on the terrain vertically below the aircraft. Obviously this cannot include takeoff and landing, or departure and approach flight paths.

3. Civil Aviation Regulation 155(1) for conducting an aerobatic flight.

“Acrobatic” flight [not aerobatic] means manoeuvres intentionally performed by an aircraft involving an abrupt change in its attitude, an abnormal attitude, or an abnormal variation in speed.

At this point however John didn’t know of Moore’s recommendation to charge him with these alleged offences. In early March 2009 he engaged Tamworth-based aviation lawyer John Glynn of McMahon Broadhurst Glynn, as his legal representation; to act for him in matters related to his AAT application. Mr Glynn advised him not to speak with CASA and undertook to contact CASA advising that John would not partake in any interview, nor have any discussions with CASA officers about the alleged incident. Most experienced aviation lawyers give the same advice, simply because of a deep mistrust based on past experiences of the purposes and conduct of “show cause” processes.

“Then I was issued with a “Show Cause Notice” without sufficient details to enable a response.”

On March 26 2009 John received a “Notice of Show Cause” signed by CASA’s Northern Regional Manager of General Aviation Operations, Gerard Campbell, which referred to a ‘DVD’ which had been posted on ‘You Tube’. He wasn’t provided with a copy of the images and the item on the You Tube website had already been deleted. Furthermore the notice didn’t identify ‘the flight’ by date, time, place, point of departure or destination, nor did it identify the passengers who were on ‘the flight’, or the pilot. For those reasons Mr Glynn didn’t consider this notice complied with the rules of procedural fairness because neither John nor his lawyer had been given sufficient details to enable a response.

This was the beginning of a lengthy series of events that raises questions over the quality of CASA’s investigation and of the degree of diligence with which its evidence was assessed. Many of CASA’s misstatements were only corrected from information provided by Messrs. Quadrio and Glynn. The corrections included the time of commencement of the flight, the location, the identity of the operator, and some assertions made by the witness who took the video clips.

“I responded and some more details followed but not enough.”

Two weeks later Mr Glynn responded to the Show Cause Notice. He asserted that the video did not depict the events alleged in the Notice, denied that the footage identified John, disagreed that the images showed the helicopter was performing “acrobatic and abrupt flight manoeuvres,” and specifically disputed that the helicopter was shown to have flown in the following manoeuvres [as accused]:

  • Descending sharply so that negative gravity forces were felt by the passengers;
  • Very steep turns in excess of 60º angle of bank at altitudes of 100 feet or less;
  • Buzzing” of a motor vessel moored at Norman Reef on more than one occasion at a height between 20 and 100 feet above the sea.”

 “I responded again advising that my log book has me at a different place and time on that date so they amended their notice to match my details.”

CASA simply switched the scene of the alleged misconduct to Hastings Reef, altered the time of the events, and “gave us 10 days if we wished to make some further response to the amended Show Cause Notice.”

However, Mr Glynn continued having difficulty extracting material CASA had relied upon, and which it was obliged to provide, including the particular video segments which they claimed confirmed many of their allegations.

“CASA cancelled all my licences”.

Instead, on June 30 2009 CASA sent John a Notice of Cancellation of your commercial Pilot (Helicopter) Licence. Signed by CASA Group General Manager Of General Aviation Operations Group, Greg Hood, the letter repeated the earlier three allegations, but with the addition of:

iv. “Acrobatic and abrupt flight manoeuvres” [which if substantiated would have constituted aerobatic flight.]

John was now earning a trickle of income from farm labouring on the Atherton tablelands.

“My lawyer had to attend numerous hearings at the AAT because CASA was withholding evidence and we could not adequately respond.”

Because an application for review had been filed with the AAT, CASA was now compelled to supply to John and to the Tribunal within 28 days, all documentation upon which it relied, to make the decision which was now being appealed. (The “T documents”)

There followed a paper war of attrition as Mr Glynn strove to obtain the documents and video footage, stating at one point: “We are seriously concerned that you have deliberately made available to us a video that appears to have been manipulated, or is incomplete.”

By this time John Glynn had been provided with various statements from CASA witnesses, including those of the passenger who took the videos, Benjamin Coglan, and his companion on that day, Michael Jentsch, who observed the flight from the surface.

On July 31, 2009, John Quadrio provided further corrected details, including his response to an allegation by Coglan that John had deputised him to make a pre-departure radio call. This was later acknowledged to be another fabrication.

CASA’s Evidence at this point comprised statements from seven witnesses:

  • Michael Jentsch, the maintenance engineer who allegedly observed the flight (Jentsch was not an aircraft maintenance engineer; he was employed in the hospitality industry). His statement got it seriously wrong. He had located the alleged incident on the wrong reef, saying that when he witnessed these events from the surface he was at Norman Reef, which is six nautical miles north of Hastings Reef. To add to the confusion he even described the two pontoons there. There’s only one pontoon at Hastings Reef. There’s also considerable helicopter activity in the area, but on the day in question John’s aircraft flew only from Cairns to Hastings Reef, conducted one scenic flight, and returned to Cairns. It seems highly likely that in reporting on some events, one or both of these two witnesses observed the operations of other helicopters at another location and confused them with VH-HTE.
  • Benjamin Coglan, an associate of Jentsch, was the passenger who took the video: Some of Coglan’s evidence also seemed to suggest that the pair may have confused John’s aircraft (which had only conducted one flight on that day) with other helicopters operating in the area. Coglan also said John had asked him to conduct radio communications with Airservices, which (besides being highly improbable) would also have been physically impossible because he (Coglan) would have had no access from the passenger seat to a working microphone. It’s not known how CASA carefully assessed this witnesses credibility. In fact, under cross-examination in the AAT he later conceded he had untruthfully represented himself as a “Qantas first officer” and elsewhere that he had “10 to 12” hours flying experience but he eventually admitted he had never held any pilot licence including a student licence at any time. When asked, he explained that his reason for describing himself as a Qantas pilot was “because the girls like it.”
  • Dennis Allwood, FOI and designated expert witness – the FOI who had spoken to John and who had also viewed the videos. Allwood made demonstrably incorrect assertions about the operation of inflatable emergency floats on R44 helicopters and inaccurately interpreted the specifications of the Pilot’s Operating Handbook in respect of the arming of the floats. He also appears to confuse ‘arming’ the floats (priming them for deployment) with ‘deploying’ them. His evidence did not support that of his colleague Ms. Lutze, and his statement also contained assertions that the video footage showed the helicopter conducting “aerobatic manoeuvres.”
  • Yvette Lutze, FOI and designated expert witness, who had also viewed the videos and who appears to have had eventual reservations about the accuracy of her assessments. CASA later advised John and Mr Glynn that Ms Lutze was no longer able to give evidence because she was required to care for her mother full-time, following a serious accident. However John later heard from a reliable source that Ms Lutze had already left CASA and was attending a night vision goggle training course in Tasmania. Ms Lutze’s statement also repeats some of Mr Allwood’s statements regarding float operation and deployment, and “aerobatic” manoeuvres.

Her statement continued: “….. The helicopter appears to have large angles of bank. Based on the footage, these appear to be in excess of 70°. This observation is drawn from where the horizon crosses the windscreen.”

  • Malcolm Walker, FOI, whose evidence varied little from that of Allwood and Lutze. His statement contained similar interpretations from the video of low-flying, steep turns, and “large angles of bank, possibly in excess of 60° based on where the horizon intersects with the windscreen.” It also contained the now-familiar warnings cut and pasted from the R 44 flight manual stating that “abrupt control inputs produce high fatigue stresses and could lead to a premature and catastrophic failure of a critical component.” There was considerable emphasis on steep turns, and a dissertation on associated risk including possible loss of height reference, unintentional loss of altitude, and retreating blade stall, which he described as “a phenomenon associated with high speed, high gross weight and high rotor disc loading such as at present in a steep turn. Instances of retreating blade stall in helicopters such as the R 44 quite often result in mast separation.” The relevance of those observations was not explained in subsequent deliberations.
  • David Ringrose, designated expert witness – an examiner of forensic imaging – provided an opinion by reference to still images/photographs. This disregards the actual operation of a moving helicopter, possibly because that would be outside his professional experience. His expert evidence also created significant doubt about Lutze’s interpretation of the video. Mr Ringrose also alleged that the helicopter had been flown at or near a 70° angle of bank.
  • John Beasy, FOI and expert witness, took a countervailing view to that of Ms Lutze and Mr Allwood, which appears eventually to have convinced the DPP to withdraw criminal charges against John.

“Nine adjournments followed as it slowly dawned on the Department of Public Prosecutions (DPP) that the case was flawed.  They had lost most of their witnesses.”

To provide time for all that material to be evaluated, the matter was adjourned to August 6, 2009. This was the first of a string of adjournments that continued for about a year while CASA and the DPP strove to put a case together. Most of these were attributed to the need to gather and assemble more evidence, which appears to differ from normal policing practice, in which evidence is carefully gathered and assessed before a decision is made to lay charges. AviationAdvertiser has several well-documented examples which illustrate this syndrome.

Although it didn’t emerge until much later, CASA Senior Airworthiness Inspector Peter Larard had sought and obtained comment on the video footage from the aircraft manufacturer, Robinson Helicopters. He informed Moore as early as May 21, 2009, well before the DPP became involved, that he had made enquiries with Robinson in relation to the airworthiness of the helicopter after the manner it was flown. Larard E-mailed Moore, saying: “in short, Robinson said there were no maintenance issues as far as they were concerned.” This information does not appear to have been shared with other CASA decision-makers, to the defence as required by law, or to the DPP.

CASA’s eight CDs were eventually delivered by courier to Mr Glynn’s office in Tamworth but too late to post them to John for viewing before the hearing, and very significantly too late for any detailed analysis at all. They were too big to email so Mr Glynn was forced to request a further adjournment to allow time for them to be reviewed.

On October 12 2009 Mr Glynn filed a second application to the AAT seeking a stay, based on the assertion that it was unfair and prejudicial to John, to be forced to conduct proceedings in the AAT whilst there were threatened criminal prosecutions.’

He also noted: “Another concern that we have is that the Brief of Evidence was forwarded to the DPP on 1 July 2009 and at this stage, no charges have been laid. It would appear to us that there may be significant deficiencies in CASA’s case and that they may be awaiting your evidence at the AAT hearing, to then prepare a criminal case.”

However, because it had effectively achieved John’s grounding in a single meeting from which he was excluded, CASA certainly appeared to be in no hurry to meet the challenges it still faced.

Eventually AAT Deputy President Hack SC gave his Judgment on the application for a stay, concluding that not granting it would cause John significant hardship, given that there were most likely criminal proceedings to be commenced, and the AAT matter could not proceed while they were afoot.

But he also directed that John notify CASA of any employment that he obtained as a commercial helicopter pilot, and also: “Within 14 days of the end of each quarter, commencing on 31 December 2009, he deliver to the Cairns office of CASA his Pilot’s Log Book for inspection and/or copying.”

That left John Quadrio back where he started:

“I am innocent and I refused to accept a punishment for something I didn’t do, so I would not go back to work if I had to present my log book to CASA every three months like a criminal on parole. Also I hadn’t flown for almost a year now, and with no guarantees I was not prepared to pay for expensive refresher training, biannual flight review tests, pilot medicals and other attendant costs.”

On November 13 2009 Mr Glynn was formally issued with a Summons served by the Commonwealth DPP, charging his client with three criminal offences and requiring him to appear at the Magistrates Court in Cairns on December 10 2009 – which was later deferred.

The AAT Hearing was now on hold until the criminal matters had been dealt with, and CASA’s attentions were turned to reshaping the evidence it had prepared for the AAT, to meet the more rigorous standards of a criminal court.

On the following day John was bailed to then “appear and surrender into the custody of the Magistrates Court at Cairns on 4/02/2010.” The notice listed seven “undefined offences”

Just prior to the mention the CDPP advised Mr Glynn that the prosecution: “intend relying upon FOI Allwood and FOI Lutze as experts in the case;” and: “are considering calling some engineering evidence as to the effect of the aerobatic manoeuvres on the airframe.”  As we’ll see the DPP had already been denied important information on that issue that might otherwise have caused an earlier discontinuance of proceedings.

On May 12 2010 the CDPP advised Mr Glynn he did not at this stage intend calling any evidence from an expert engineer and would be relying upon the evidence of Dennis Allwood and Yvette Lutze.”

Two days later CASA advised that its prime witness Mr Coglan had been located, but inconveniently he was in prison and not due to be released until July 1. This news may have been the reason the prosecution had indicated it wanted the matter to run entirely on the videos without the necessity of calling any of the ‘civilian’ witnesses (Jentsch and Coglan.)

Comment: One might expect that the DPP, its fingers having been similarly burned in the course of numerous other CASA legal adventures, might by now have begun to have reservations as to the quality of the legal preparation it had to work with. Up to this point there doesn’t appear to have been any competent analysis at all as to how a Robinson R44 helicopter pilot might have sustained a 70° banked turn without destroying or seriously damaging the helicopter, pulling something in excess of 3g (if Lutze’s assertions were correct), losing more height than remained available beneath the aircraft, and killing all its occupants. Various CASA witnesses had now estimated the bank angle successively at 60º (twice) 70º, 85º and 70º again. They had described flying conduct that was physically impossible, demonstrated their inability to examine and report accurately on technical issues, and also to read and understand a flight manual and other technical data correctly.

Attitude or altitude?

Two recurring themes in the analysis of the available data were the estimates of bank angle, and the presence or otherwise of “G” forces, neither of which seemed to be fully understood either by some of the technical witnesses or (later) by CASA’s lawyers. Much of the dialogue suggests a lack of awareness of the distinction between positive and negative G, and also of the fact that one G is the normal state of things.  G levels between zero and 1G are sometimes mistakenly referred to as “negative G.” Zero G is what a child experiences at the top of a swing because centripetal acceleration from the swing (the motion having ceased) is absent. In an aircraft it will cause objects and unsecured people to be weightless like astronauts in a space shuttle. A negative G condition will cause the same objects and people to accelerate in a straight line towards the roof of the aircraft.

Ms Lutze’s lengthy discourse regarding bank angles and G forces asserted:

“For example the load factor at 45° angle of bank is 1.4. At 60° angle of bank the load factor is 2.0, and 75° angle of bank load factor is 4.0. Load factor is the ratio of the lift on aircraft to the weight of the aircraft. Load factor is expressed in multiples of G where one G represents conditions in straight and level flight. To avoid descent due to increased load factor of high angles of bank, the collective must be significantly increased during a sustained steep turn. The power demand to overcome the increased drag from the increased collective blade pitch angle must be matched by the power from the engine. There is a limited amount of power that engine can produce. Once this is exceeded and the engine can no longer produce enough power to drive the rotor system, the rotor RPM will decay and rate of descent will develop. To further attempt to reduce rate of descent and avoid collision with obstacles, the pilot is likely to instinctively apply aft cyclic control to decelerate in attempt to trade speed for height. In conducting turns with large angles of bank at low level (in this case under 100 feet AMSL) risk is significantly increased due insufficient height to recover in the event of a descent.”

This, when rationally analysed, actually suggests that the passengers would have been subjected to a load factor in the order of 4G. Had anything like that been the case, the dire outcomes she went on to describe would certainly have occurred, and neither the passengers nor John Quadrio and the aircraft, would be likely to have survived. Exposure to forces of between 1.5 G, and 3G, would be an experience that any passenger, and most pilots, would find memorably upsetting and possibly disabling.

Author’s note: For the remainder of this article, the bracketed numbers in the commentary for example (para 25) refer the reader to the relevant numbered paragraph in the AAT decision document, which is available at: http://www.austlii.edu.au/au/cases/cth/AATA/2011/709.html.

On the subject of bank angle there were several references in the witness statements to “the angle between the windscreen and the horizon” and varying other estimates of the actual bank angle (Paras 25, 31, 54[b], 62).

Unfortunately Mr Baddams had accepted that he should defer to the expertise of Mr Ringrose on the issue of observable angle of bank, and even more unfortunately Mr Ringrose’s estimate of “67° to 70°” went unchallenged, (Para 25) leaving it as the definitive statement even though it was totally inaccurate. It is possible that it was left unchallenged because John and/or Mr Glynn believed the Tribunal would see it as a nonsense.

Assessment factors

Given that the videos were shot by a passenger sitting in the left front seat, the only airframe components which might aid in the measuring of the aircraft’s attitude in relation to the horizon are the divider between the left and right panels of the windscreen itself, and very occasionally parts of the instrument panel pedestal. To make any of these estimates credible, other matters need to be taken into account. These are the actual shapes of those aircraft components, the focal length of the lens, which considerably distorts the perspectives because it varies as the lens is zoomed, the alignment of the camera with the yaw, roll and pitch axes of the aircraft, the actual motion of the camera, its positioning in relation to the visible aircraft reference structures, its lateral and vertical movement around the cabin, and the motion of the aircraft.

In the main, the lack of understanding of those elements which is revealed in the various expert witness statements is dismal. That is unsurprising because the training and testing that leads to the tenure of a pilot licence does not include developing the talent to derive technical assessments from video footage.

Let’s take a look at “Exhibit E,” the clip that received the most attention. While you’re watching, keep in mind the considerations in the paragraph headed “assessment factors” above.

Reckless flying

Technical witnesses who provided statements also made various assessments of the height and the vertical speed (rate of climb/descent in feet per minute) of the helicopter during the flight, but did not always provide references as to how they assessed the height at any given time.

For example, Mr Allwood made one height estimate on the basis of the visible shadow of the helicopter on the surface, stating: “The helicopter’s shadow on the reef can be seen, confirming the low altitude.” However, it confirms nothing of the sort if photographed through a zoom lens. The use of a zoom lens at various times during this adventure is clearly evident in some of the video shots, and the single glimpse of a helicopter shadow in one of the clips is totally inadequate to make any assumptions on height.

The attitude of the aircraft, and changes in attitude, also received a good going-over from most of the technical witnesses, but these were limited to phrases such as: “intentional and involved abrupt change in the helicopter’s attitude,” (Mr Allwood), and “low level, steep turns, with abrupt changes in attitude and rate of descent (Ms Lutze.) Not one of these statements about abruptness was quantified in terms of rate of roll, pitch, or change of heading. It became obvious that the reasons for referring to “abrupt changes” is that they are quoted as one of the elements of “aerobatic flight”, and also form part of the legal definition of the alleged offences.

And of course, all these assertions were peppered with summaries and warnings from the flight manual of the dire consequences of illegal aerobatic flight, ignoring the response from Robinson Helicopters, which had apparently not been provided to these experts.

By now, a series of qualified CASA pilots appear to have shied away from further involvement, and eventually CASA heeded advice from somebody who effectively confirmed that had been the smart thing to do. That was (then) CASA FOI John Beasey, who had advised CASA in an e-mail that CASA would be unlikely to prove any of the charges “with the possible exception of low-flying.”

The prosecution must have agreed with that because the court was advised of the CDPP’s decision to discontinue the proceedings and was adjourned to 16/11/2010 for the purposes of John’s Cost Application.

John recalls: “On 16/11/2010 the [AAT] judge asked the CDPP why they went through with it and what made them pull out. The CDPP said Lutze had pulled out and that led them to get their own expert witness [Mr Beasy] who told them that there was no case to answer, and that is why they were pulling out now.”

By now John Quadrio hadn’t flown for 2½ years and his licence cancellation remained. But the administrative decision that dumped him in that position had not been reversed.

In March 2011 Mr Barry Dick, a highly experienced commercial helicopter pilot, instructor and operator, having studied the statements of Lutze, Jentsch, Allwood, Coglan and imaging specialist Ringrose, provided an affidavit which included a highly detailed and critical analysis on the previous statements of the CASA witnesses.

A similar statement provided at that time by Mr David Baddams, another amply qualified military and civil pilot, provided strongly supporting input with logical and definitive analysis of the kind which had been lacking in the statements of most of the CASA officials.

Back in the AAT                                            

The AAT reconvened in Cairns on June 14, 15, and 16, and Sophie Quadrio’s mother Helen Irvine provides an impression from the “members’ stand:”

“Talk about David and Goliath! CASA had a barrister, Shields, from Sydney as part of their team of nine “heavies” most in black shoes, black suits, shaved heads and sunglasses. Many of them had flown up from Sydney or Canberra. They were intimidating and looked smug and I couldn’t understand at first why such a trivial case from CASA’s point of view? I mean it wasn’t like a plane crashed or anyone got hurt so why would they need such a huge team to decide if John should get his licence back AFTER they had dropped all criminal charges without going to court just before Christmas?”

Piecing together the observations of various witnesses, it became apparent that CASA’s case was not looking good, a view which one of its officials ruefully confided to one of our observers, possibly mistaking him for a colleague.

One thing every CASA inspector was unanimous about was that John had been low flying illegally, and the regulation regarding height above terrain was smugly read out.

Of course, as the DPP had already been aware, a submerged coral reef does not meet the dictionary definition of “terrain,” and the nearest geographical feature to Hastings Reef that meets that definition, would be Cape Grafton, some 23 nautical miles to the south.

“You could almost hear the sound of jaws dropping,” recalls one of our court room observers.

Next issue was “illegal G forces.” Mr David Baddams is a former Royal Navy Sea Harrier fighter pilot and therefore an expert on G forces. When a CASA lawyer apparently sought to discredit him by suggesting that he knew nothing about hovering or landing on objects like pontoons, Mr Baddams was pleased to be able to put him straight. Frame by frame through the video at the point where CASA claimed significant G-force had existed, he showed that Coglan raised his camera to photograph upwards and the girls in the back raised their hands. Baddams pointed out that no upward passenger movement would have been possible if John had been inducing any significant G forces at all.

Baddams also identified that the manoeuvring is: “not abrupt or abnormal, particularly if the aircraft is inspecting the landing area to ensure it is clear, prior to conducting an approach.” He stated: “The conclusion I draw from this video is that no significant G forces were present above 1G.”

And noting that both FOIs Lutze and Walker relied entirely on one of the exhibit videos, and FOI Lutze on her observation of “appears to be in excess of 70°” and elsewhere…. ‘Possibly in excess of 60°’ he commented: “I consider this assertion to be incorrect and not supported by the evidence in the video.

FOI Walker had not established any basis for his allegations regarding the angle of bank that was shown in the video, but ultimately admitted, while still giving evidence, words to the effect that: The truth is none of us can tell anything from the videos, because there are not enough reference points. We are all only making assumptions. The observers saw this as another damning admission, and there were more to come. (NOTE: we do not have access to the transcript of this part of the hearing; however the above quote is from the collective memories of three separate people who were in attendance.)

When FOI Allwood was cross-examined on the question of steep turns, he said he could manage to read the manifold pressure gauge on the instrument panel from the videos, and the needle was pointing straight up; therefore the pilot was using 25” manifold pressure, which represents close to full throttle power as would be required in a steep turn.

John says he was encouraged to experience one serious steep turn at a 60° bank angle in the course of his low flying approval training, and that was enough to give him a lifelong aversion to high G steep turns.

Under cross-examination, FOI Allwood repeated his assertion that the application of 25 inches manifold pressure would be normal and necessary in a steep turn, but confirmed it would not be used in a wingover.

At that point John Glynn produced a clear close-up photograph of a Robinson instrument panel, which shows that when the manifold pressure needle is pointing straight upwards, it is actually indicating 20-21” mp, comfortably below normal cruise power, which is perfectly consistent with the execution of a wing-over manoeuvre.

This, according to some who were present, proved to be something of a showstopper, with various members of the CASA team exhibiting symptoms of severe embarrassment and/or distress.

Before adjourning in Cairns, the tribunal required both sides to provide their final submissions, ordering CASA to surrender all the previously withheld evidence, including one video clip that had been omitted from the set, and to provide contact details for Mr John Beasy – the CASA FOI who had finally recommended dropping all the criminal charges.

The hearing was adjourned on June 16, 2011. The AAT normally expects to deliver its findings within two months. The AAT decision was delivered on October 12, 2011 – almost four months after the adjournment and can be viewed at: http://www.austlii.edu.au/au/cases/cth/AATA/2011/709.html

The situation at that point:

The AAT decision centred on four factors – low flying (para 38-49) aerobatic flight contrary to the flight manual (para 50-53), reckless operation of the aircraft (para 54), and unsafe operation (para 65).

1.       Low flying

The tribunal’s finding was that quite a lot of the depicted flying was below 500 feet, “at heights and speeds that were contrary to the manufacturer’s recommendations.” It rejected the argument regarding the legal definition of “terrain”, saying it was “absurd” to think the rule was intended to exclude minimum altitudes over water (para 46, 47). It also rejected John’s explanation that the wingover manoeuvre may have been due to traffic or bird avoidance, and repeatedly described these assertions and the statement that he could not recall the particular flight as “simply not believable” and “risible.” (para 72)

2.       Aerobatic flight contrary to the flight manual

The finding was that this complaint was “not made good.” The Tribunal noted that the manufacturer had viewed the footage and it and remained unconcerned, providing the inference that the Robinson representative didn’t regard the depicted moves to be contrary to the flight manual.

3.       Reckless operation of the aircraft

This issue had four elements. The tribunal didn’t accept the allegation of negative G forces, and also rejected allegations of “buzzing” the tourist boat. (Para 55 & 58)

However the allegations of bank angles in the order of 70° were accepted (para 62), as was the claim that the flying involved “abrupt changes in the altitude” of the helicopter. This finding is not understood, because it is “abrupt changes in attitude”, not “altitude”, which (present other factors) can be an identifier of “aerobatic flight.” We have to assume that the acceptance of both the bank angle and attitude/altitude (whichever was meant) assertions relied on Mr Ringrose. It seems unfortunate that somebody didn’t explain to the tribunal to the difference between altitude and attitude. It is also unfortunate that assertions of “abrupt changes of attitude” were not required to be quantified in terms of the rate of roll or rate of pitch change in terms of degrees per second, which are common values used in contexts of this kind.

“Negative G forces” were finally knocked on the head as well (Para 55), possibly because it was realised that this had been a fanciful description all along.

4.       Unsafe operation

Repeating its rejection of John’s “reconstructed excuse for this manoeuvre,” the Tribunal re-asserted that the video/audio revealed no sign of possible threats such as conflicting aircraft or bird life. That, and the voice of Mr Coglan on the video saying “that’s awesome” was interpreted by the Tribunal as evidence that there were no birds or other aircraft in the area. (Para 60). This appears to be consistent with the tribunal’s advice (para 36) that “the Tribunal is not bound by the rules of evidence,” which is an important point to remember if you are ever in a similar situation..

Our expert witnesses 01

We have been in contact with three experienced civil helicopter pilots with an average of something over 15,000 helicopter hours each and strong backgrounds in all areas of helicopter operations and pilot training. We will not identify any of them because all hold current Australian licences and other regulatory permissions, but the three have viewed a draft of this report and the AAT decision. Separately we have discussed this with Mr Barry Dick who has advised us on these issues. All are unanimous in believing that a grave injustice has been done, and extremely blunt about CASA’s conduct in certain of the matters we have discussed here.

  • Grounding of the pilot

“This all started at the meeting between Allwood, Quadrio and the about-to-be chief pilot. That’s where it should have stopped until it had been properly investigated. I believe it should now be investigated as to whether the company was coerced – obviously illegally if it did happen – into firing him. Allwood could have sought authority to suspend his licence through official process and didn’t. I think your analysis of this farce explains why. They never had supporting evidence and they still don’t, but when one of their officials makes a blunder like that they don’t investigate it or reverse it, they close ranks behind this official and do whatever it takes to cover it up, including destroying people’s lives.

“In my view CASA should be investigating the exact circumstances in which the pilot was grounded.”

Comment: If John Quadrio’s version of these events is correct, it would appear that at least one CASA official has improperly exceeded his authority, causing this pilot considerable financial harm and damage to his reputation. It is obviously open to CASA to investigate whether this is the case. If the CASA official did not use coercion such as the threat of “adverse audits” or the non-endorsement of the chief pilot approval application, and if Mr Mackenzie’s decision was voluntary, it would seem that John would have a strong case against the company for unfair dismissal.

  • Dramatisation of flight manual material

“Some of those CASA witnesses talked absolute [cattle mustering expression meaning ‘nonsense’] about retreating blade stall and rotor mast separation, which as far as I know has NEVER happened in a Robinson or any other aircraft except in test flying, and possibly not even then. Basically it’s a theory and applies only in high speed and overloaded operations, so it’s not relevant to this case and seems to be something thrown in to dramatise the alleged risk.”

“I can’t put it better than this info from this web-based commercial helicopter forum:” One thing to keep in mind as you look at these HV curves is that they are not limitations placed on the pilot. If they were intended as limitations, they would be placed in the limitations section of the flight manual. Instead, they are placed in the performance section as a guide to the pilot, so he can make intelligent choices about what combinations of airspeed and altitude to use for a particular mission. Some missions require you to fly the helicopter in the shaded area of the HV curve. While doing so, good pilots are spring loaded to react immediately to any clues that something may be wrong with the aircraft, and they will attempt to get out of the shaded area immediately. Operating in the shaded area of the HV curve involves risk to the aircraft and its occupants, and the risk must be managed wisely.

“That didn’t stop CASA from convincing the Tribunal that Quadrio flew in an unsafe way. If you look at the R44 HV curve for the takeoff flight path it is unusually flat, because it’s a modern helicopter with a much lighter composite main rotor which means it has low inertia and is more quickly decelerated by aerodynamic forces. In fact one of Mal Walker’s accounts [on Exhibit B] details a low-level acceleration that fits almost perfectly into the R44 HV curve.

“The manual doesn’t say you can’t, the advice is to avoid it. It says that if you’re below 500’ and the engine stops you may not be able to do a safe autorotation, depending on circumstances. I can do a hovering autorotation from 200’ and yet the graph says I can’t do one from 500. It’s a matter of experience and judgement and intelligent risk management. It doesn’t mean you’re taking a lot more risk unless you’re worried about going from one in 100 million versus one in 99.9 million. If you slow down to show them a turtle it’s hardly suicidal I think, because a couple of seconds at reduced speed represents a statistically negligible increase in risk exposure -far less than attends most approaches and departures.


Some quotes from the decision with editorial comment:

The Authority submits that Mr Quadrio ought be regarded as being unreliable. It points to variations in his account of events and to variations between Mr Quadrio’s account and that of Mr Coglan. And, it submits, the discs show no evidence that would support the notion that Mr Quadrio flew in the manner depicted to avoid a hazard.

Comment: Well, CASA would submit that, wouldn’t it? From various matters revealed in the course of the hearing, one might have thought that the more difference there was between John’s and Mr Coglan’s account of events, the more reliable the Quadrio version was likely to be, than that of somebody who has professed to be a Qantas first officer with 12 hours flying experience.

Mr Coglan can be heard in disk E saying “that’s awesome” and “that’s unreal” in response to the figure .(the You Tube footage is no longer available.) Sophie’s superimposed voice describing the flight as “awesome” and “unreal,” inserted from the comfort of their home, can be clearly heard.
Update comment December 9 2001: Please note that at CASA’s request we emphasise that this footage was taken on a separate flight and there is no intention to depict it as being part of the original footage.

“…… That conclusion (that Mr Quadrio was not a fit and proper person) is fortified by Mr Quadrio’s subsequent actions….”


“We are more concerned that Mr Quadrio, from the outset and during the hearing, professed no recollection of the flight and advanced a patently risable [sic] story to account for his flying on that day.”

Comment: “Risible” is misspelt twice in the text. It means “causing or capable of causing laughter” and the comment ran the unfortunate risk of being interpreted as arguably a gratuitous insult from an institution whose published values include “integrity, professionalism, efficiency, accessibility and independence.”

There is no record to suggest that John ever at any time denied being “the pilot in charge”; he simply stated at all times before and after his identification was confirmed, that he did not recall this particular flight. Any pilot doing repetitive flying of this kind would confirm, as this 14,000 hour pilot/aviation writer can, that unless something very unusual happens during such a flight it’s very unlikely to stick in one’s memory. Having conducted something over 1,400 round-trip flights between Rockhampton and Great Keppel Island (as one example), I would estimate that on something like two thirds of those flights, a departure from optimum flight paths would have occurred because of weather, ATC requirements, conflicting traffic outside controlled airspace, people/vehicles/animals/aircraft on the runway, and even inconveniently placed yacht masts on short final. You manage one issue at a time and move on to the next. In fact the only flight of which my memory retained any detail at all was the one when I passed within three metres of a Beech Baron which was traversing the area and enjoying the scenery in radio silence.

In fact at Safeskies 2011 last week Dr Kathy Abbott, Chief Scientific & Technical Advisor on Human Factors for the FAA, said of a recent FAA study: “Only ten per cent of all flights proceed according to plan.”

That point is made because of the way in which CASA and its team of expert witnesses, all but one of whom was on the CASA payroll, was able to convince the Tribunal that it was ridiculous for John to claim that he couldn’t remember the details of a particular flight. Expert witnesses will be discussed in more detail later.

Mr Quadrio’s inability or unwillingness to acknowledge his demonstrated shortcomings only reinforces our view that he is not a fit and proper person to have the responsibilities and to exercise and perform the functions and duties of a commercial pilot.

The second aspect concerns Mr Quadrio’s suggested explanation for the manoeuvres shown in the film. As we have said we regard those explanations as risable.

Comment: There’s “risable” again. Well, most of us have a little list of risible courtroom comments off the Internet, so here’s one we can add to your collection, delivered by CASA lawyer Mr Shields when cross-examining Barry Dick:

Mr Shields: “So the aircraft’s going to pick up some height as it goes up?”

Mr Dick: (straight faced) — “Yes.”

Comment – expert witnesses: On less risible issues, some observers were also critical of what they believed was a tendency for the Tribunal to elevate the experience levels of CASA’s expert witnesses Allwood and Walker in comparison with their characterisations of the applicants’ expert witnesses Dick and Baddams:

  • “Mr Allwood is an experienced pilot with over 10,000 hours experience on fixed winged aircraft and appropriately 500 hours on helicopters including the Robinson R44.” Yes, that sounds like a respectable amount of experience.
  • “Mr Malcolm Walker is a flying operations inspector employed by the Authority with vast experience in military and civilian flying and in excess of 10,000 hours in helicopters.” Yes, that too sounds like a respectable amount of experience. But……
  • “Mr Dick, a helicopter pilot of considerable experience” omits to mention that Mr Dick’s flying experience amounts to 17,500 hours flying, of which 14,500 have been in helicopters and over 6,000 instructing in both ab initio and advanced training in every facet of advanced helicopter operations including international operations, and has written serious articles and books on the subject.
  • “Mr David Baddams is a very experienced military fixed wing pilot albeit with some little experience as a helicopter pilot.” CASA’s lawyer actually suggested Mr Baddams might not know much about hovering or landing on objects like pontoons. He overlooked the relevance of Mr Baddams’ experience in vertical takeoff and landings in Sea Harrier jet fighters on aircraft carrier decks in all weather and light conditions. (The lawyer is now better informed.)
  • Ms Lutze’s helicopter experience amounted to 716.9 hours. (which is almost equal to John’s experience at that time.)
  •  Mr Walker’s helicopter experience totalled 12,000  hours, some 10,000 of which are helicopter hours, and his background suggests that if bird life was evident in the video footage  that he would have detected it in his detailed examination.

Nor was the tribunal finished with Mr Dick, who inadvertently transposed north and south when sketching a flight path diagram. The Tribunal concluded: We do not think that we are able to place any great weight on the opinions expressed by Mr Dick.

As cartography doesn’t appear on the commercial pilot licence syllabus the casual observer may see this observation as a little harsh, so let’s see what’s said about Mr Allwood’s apparent inability to read an everyday aircraft instrument like a manifold pressure gauge correctly; and let’s not forget that was one factor that led directly to John’s grounding: “When he spoke of the observed engine manifold pressure supporting his characterisation of the figure of eight manoeuvre not being a wingover ….. he was demonstrated to be in error. But we are, nonetheless, satisfied that we can act upon the factual components of Mr Allwood’s evidence.”

For the moment, enough said on that issue.

The Tribunal had made it abundantly clear that it didn’t accept John Quadrio may have turned the aircraft suddenly to avoid bird life, and must have been so convinced by CASA’s input that the AAT repeatedly poured scorn on that scenario.

AviationAdvetiser’s research

Exploring the bank angle issue, AviationAdvertiser decided to deploy the full resources of our mini-aeronautical research laboratory/garage to the question of bank angle. We began by building a scale model of the left side of the R 44 cabin to provide a clue to anomalies detailed by CASA’s witnesses, had they chosen to check their facts. The metal eyelet in these diagrams represents the notional position of the camera, so that looking through it provides a camera view.

Appointing myself (Paul Phelan) as our expert witness, I will just summarise as expert witnesses do, my relevant credentials:

  • over 14,000 hours total flying experience in general aviation, corporate and regional airline operations; no significant helicopter experience.
  • a large amount of low-level flying between 35 and 40 years ago, flying researchers from various agencies over the outer and inner Great Barrier Reef to observe, catalogue and photograph migratory birds from Heron island and the Swain reefs in the south to Princess Charlotte Bay in the north.

Here is a summary of our findings:

Figure 1

In this image the helicopter is in level flight but banked 45° to the left. The perceived angle of bank however is only 22° at the point where the windscreen divider intersects the horizon.

Figure 2

In the above image the aircraft is in a 45° angle of bank to the left, and the nose is pitched down 10°. This has moved the intersection point on the windshield divider upwards, altering the perceived angle of bank of 45° back to 13°. The above two images therefore illustrate the difference in bank angle perception which occurs when the nose is raised or lowered.

Figure 3

In the above image, although the model is in level flight and banked 45° to the right, be perceived angle is 88° because the part of the divider intersects the windscreen, apparently intersects it at that angle.

Figure 3 above should be compared with a still from the video at Figure 4. It is images of this kind that were obviously the basis of assertions about 67° and 70° angles of bank; however any such assumptions would obviously be invalid because those who made them had no way of knowing the relativity of the windscreen divider to the vertical, the spatial location of the camera, and whether it was rotated any particular direction, let alone any considerations of perspective. In fact, the best estimate from this image would be the angle between the small visible longitudinal section of instrument panel glare shield and the horizon which suggests a bank angle of approximately 34°, and even that estimate is unreliable because of perspective considerations and the obvious twisting of the camera to the right around the longitudinal axis of the aircraft.

Here’s another angle to explain Mr Allwood’s “vertical pillars.” Look at the horizon from a Robbo seat and you’ll see what we mean.

The arrows point to the windscreen “dividers/pillars” that the witness asserts “are vertical when the aircraft is straight and level,” which was the case with Model T fords but not much since. Now picture yourself sitting in the left front seat of one of these helicopters and looking at the point where the windscreen divider crosses the horizon. Remember you’re not looking at it from directly behind, and you’ll find that depending on how tall you are the divider will cross the horizon at about a 40° angle, so if you want it to be parallel to the horizon you’ll only need to rotate the helicopter about 50°, not 90° (See Figure 3).

Figure 4

If somebody had taken a good look at this one………………

Above is the stopped video at at or within a fraction of a second the exact point Mr Allwood was referring to when he gave evidence, i.e. at the 32-second point in the video Exhibit 8. Compare it with image 3 above and with the witness’s evidence below:

Mr Shields: Okay, are you able to express a view as to the angle of bank that was carried through that turn ?

Mr Allwood: It was certainly in excess of 60 degrees for a large part of it, and I know a lot or people talk about distortion their windscreen, but that vertical line in the middle of the windscreen – which has a vertical hole in it or beam [an apparent typographical error because it is meaningless] – when the aircraft is straight and level, that is absolutely vertical, and there are a number of instances in that video clip you can see that that is even almost parallel to the horizon.

Mr Shields: Okay.

Mr Allwood: Allowing for even a small amount of distortion, that still gives you a very steep angle of bank.

Mr Shields: Can we identify where that beam, in the first turn, is parallel to the horizon?

Mr Allwood: Almost.

Mr Shields: Almost parallel to the horizon. Okay, you stopped the video at 32 seconds.  Can you just indicate, firstly, where’s the beam that you’re talking about?

Mr Allwood: That’s the centre pillar there. You can see that that’s the bottom of the screen and there is a slight amount of distortion there, but this top part or perhaps this centre part, is virtually parallel to your eyes.


This bit of smoke-and-mirrors (apparent) nonsense probably may explain why CASA deliberately delayed handing over the videos until it was too late for a proper evaluation of this vital evidence. First, there is  no confusion in that dialogue; Mr Allwood clearly stated that the windscreen divider is “vertical when the aircraft is straight and level” and also identified it by its other name – the “centre pillar.” That assertion would clearly have been picked up had there been time to assess the video properly.

They didn’t see the birds!

Investigating these issues, AviationAdvertiser became distrustful of a great deal of the input from CASA officials which had clearly persuaded the tribunal that Mr Quadrio was untruthful in stating that he could not recollect the particular flight. This was reflected in a succession of remarks from the bench such as:

  • Mr Quadrio professes no particular recollection of the flight. He says, in terms, that it was one of many flights that he had made and there is no particular reason to recall this flight. And, while professing no recall of the flight, he surmises that he would only have engaged in the low flying and the figure of eight manoeuvre to avoid other traffic or birdlife. He did not suggest that he could recall that happening, only that such events might explain the flying. The manoeuvre he performed was, he said, a “wing over”, a standard manoeuvre to turn suddenly. (Para 17)
  • (CASA) submits, the discs show no evidence that would support the notion that Mr Quadrio flew in the manner depicted to avoid a hazard. (Para 18)
  • ….. “We do consider Mr Quadrio’s exclamation fanciful when regarded as had to what is visible in, and audible on the disks. There is no visible evidence of other aircraft or bird life”….. (Para 19)
  • “Mr Coglan can be heard in disk E saying “that’s awesome” and “that’s unreal” in response to the figure of eight manoeuvre. His reaction demonstrates enjoyment of the ride, not concern about a manoeuvre driven by a need to avoid a potential hazard.” “Para 19″
  • “but beyond that, a figure of eight manoeuvre is an improbable response to the perceived hazard because its effect is to put the helicopter in a similar position without any real opportunity to observe any perceived hazard.” (Para 20
  • “thus we reject Mr Quadrio is proffered explanation and, more importantly, consider that it is an explanation conjured up to avoid him having to explain the reality of his flying on that day.”
  • “We entirely reject Mr Quadrio’s reconstructed excuse for this manoeuvre. As we have said the audible and visual evidence from the film shows no sign of the emergence of any sudden threat……… The absence of any hint on the film that Mr Quadrio regarded the terms as a necessity for safety and our own viewing of the film lead us to be well satisfied that Mr Quadrio flew in that manner for the purpose of entertaining his passengers. It was unsafe to do so” (Paras 60 and 61)
  • “Mr Quadrio, in our opinion, operated HTE in a reckless manner that had the result of the lives of his passengers were endangered when he flew the figure of eight manoeuvre.” (Para 63)
  • “the conduct of 28 September 2 008, we think, demonstrates that Mr Quadrio was prepared to disregard the requirements of safety to satisfy a need to entertain the passengers………… We need not recite the findings that we have already made. They satisfy us that Mr Quadrio was not a fit and proper person.” (Para 70)
  • “we are more concerned that Mr Quadrio, from the outset and during the hearing, professed no recollection of the flight and advanced a patently risible story to account for his flying on that day……. We find it impossible to accept that Mr Quadrio is truthful when he asserts that he had no recollection of the flight in the details of it were drawn to his attention, and he viewed the film of part of the flight, less than two months after the flight. That assertion is simply not believable.” (Para 72)
  • “the second aspect concerns Mr Quadrio is suggested explanation for the manoeuvres shown in the film. As we have said we regard those explanations as risible. They had been conjured up to avoid Mr Quadrio confronting the reality that his flying on 28 September 2008 fell well below the standard expected of a commercial pilot. But Mr Quadrio’s inability or unwillingness to acknowledge his demonstrated shortcomings only reinforces our view that he is not a fit and proper person to have the responsibilities and to exercise and perform the functions and duties of a commercial pilot.” (Para 73)
  • “it is undoubtedly the case that pilots will from time to time, fall into error. In our view a pilot who does so and who has a proper appreciation of the importance of air safety will acknowledge the error and reflect upon it in order to prevent a recurrence. Mr Quadrio has done none of that. On the contrary he sees himself the persecuted victim of an’overly protected bureaucracy’” (Para 74)
  • “we acknowledge that the decision and its affirmation and in those great cost and hardship on Mr Quadrio and his family. And he has been put to expense, no doubt considerable expense, in resisting the criminal proceeding. These matters cannot transcend the overarching obligation to have regard to the safety of air navigation. They cannot overcome our conclusion that Mr Quadrio is not a fit and proper person.” (Para 76)

As we are about to see, the Tribunal made its decision on the basis if a fatally flawed assumption – that CASA’s expert witnesses had done the job they’re paid to do.

It is particularly interesting that while Mr Quadrio was “committing” his alleged infraction and Mr Coglan was inadvertently collecting evidence of steep turns and abrupt flight manoeuvres, that these experts were actually witnessing a bird avoidance manoeuvre –  in other words a pilot doing what pilots are paid to do: Minimising the risk to their passengers.

It is especially poignant that the more John Quadrio protested his innocence, the more the Tribunal belaboured him with gratuitous insults and hardened its attitude. One of the members was even seen to roll his eyes and shake his head when the subject came up.

When AviationAdvertiser froze frame on the image corresponding to 32 seconds into the video, the first thing we noticed was what looked like a flock of birds viewed through the windscreen.

Isolating and magnifying a handful of consecutive images over about a two-second period, we confirmed that a large flock of birds, made up of several small groups of birds, was flying across the flight path from right to left. That they are migratory birds rather than seagulls or similar random feeders is identified by their “trailing line astern” formation. Such birds commonly fly together in up to half a dozen proximate groups, and if you take the trouble to view the video frame by frame, you’ll actually see that there are at least three flocks of different sizes between 29 and 50 seconds which CASA’s experts failed to notice. At the 31 second point (see Figure 4 which captures one of them perfectly) the pilot has obviously noted that they are passing from right to left and has climbed and turned right to pass behind them.

Comment – CASA’s role:

For John and Sophie Quadrio, this whole case has been a disaster which they would now like to share with CASA and the individuals involved. John estimates that his legal costs have been in the order of $80,000, and he has lost three years of income in his chosen profession.

And this hasn’t just been an isolated aberration.

These events have numerous aspects in common with numerous similar cases I have examined in which CASA appears to have single-mindedly pursued the destruction of an individual’s life, career, reputation and financial well-being using similar tactics to those described here. These activities, many of which I have documented, seem to be characterised by:

  • Eagerness to run with almost any allegation against an individual as fact without adequate and competent investigation, and to take action simply on a ‘reason to believe’ basis, sometimes (as in this case) without any formal regulatory action at all;
  • Willingness on the part of senior managers to close ranks behind its employees, rather than concede that errors may have been made, and apparently ignoring the duty of care to test the validity of the allegations and decisions:
  • An apparent preference for dealing with individuals who are perceived to be (relatively) financially defenceless;
  • Formal signed statements by CASA individuals which often reveal a lack of awareness of case-relevant technical issues;
  • Failure to assess and evaluate witness statements and credentials accurately and competently;
  • Determined reluctance to provide in a timely manner information which CASA is legally obliged to furnish;
  • Apparent wasteful manipulation of court processes in order to prolong matters to the financial disadvantage of the other party;
  • A lack of documentation which would identify participants, managers, deliberations and processes in the decision-making process;
  • Flouting of the “model litigant” obligations by which government agencies which are bound;

One of the most disturbing aspects is that once again events have highlighted the apparent existence of an unacceptable culture permeating some elements of the Civil Aviation Safety Authority that not only allows the kind of misconduct we have detailed to continue, but either supports it or stolidly denies it exists. That kind of a culture cannot survive without the awareness of senior management. It is relevant that some of the names associated with these events he  go back more than fifteen years.

And almost everybody in the industry knows who they are. It is really time for an independent external investigation. AviationAdvertiser and (we’re sure) others can provide some suggested terms of reference.

AviationAdvertiser is in possession of copies of all documents and notes of interview from which we have quoted or adduced information.

This publication may be amended/updated as a result of ongoing input. All amendments will be recorded with date at the foot of the article.


31/10/11 – typographical errors and duplication

4/11/2011 – typographical errors, image realigned for clarity.

8/11/11 – A factual error of a technical nature

14/11/11 – Minor wording changes for clarity

10/12/2011 – Clarification